Childhood obesity is a grave concern and so far community based interventions to prevent it have been rare and far between, with little evidence that any changes (however meagre) are in fact sustainable over time and will actually lead to a reduction in adult obesity.

Thus, the Australian team of Steven Allander and colleagues must be commended on embarking on what I believe will be the first cluster randomized trial in ten communities in the Great South Coast Region of Victoria, Australia to test whether it is possible to: (1) strengthen community action for childhood obesity prevention, and (2) measure the impact of increased action on risk factors for childhood obesity.

According to the trial design published in the International Journal of Environmental Research in Public Health, the WHO STOPS intervention will involve a facilitated community engagement process that: creates an agreed systems map of childhood obesity causes for a community; identifies intervention opportunities through leveraging the dynamic aspects of the system; and, converts these understandings into community-built, systems-oriented action plans.

Ten communities will be randomized (1:1) to intervention or control in year one and all communities will be included by year three.

The primary outcome is childhood obesity prevalence among grade two (ages 7–8 y), grade four (9–10 y) and grade six (11–12 y) students measured using established community-led monitoring system (69% school and 93% student participation rate in government and independent schools).

An additional group of 13 external communities from other regions of Victoria with no specific interventions will provide an external comparison.

All of this makes sense and is highly commendable.

What is shockingly lacking however – at least I see no mention of this in the published study design – is the inclusion of an explicit focus on what such community interventions aimed at reducing childhood obesity, will do to self-esteem and body image of the kids involved and weight bias in the communities overall.

Indeed, I see no mention of anyone with an explicit expertise in weight bias or kids mental health on the panel of researchers involved in this study.

This is concerning, as we now understand well that body image concerns and both implicit and explicit weight bias begin in kindergarten-age kids and must acknowledge that the “moral panic” created around childhood obesity has been accused of further promoting eating disorders, body image issues and weight bias.

Thus, we have here the unique opportunity to study the potential harm that could be done by school “surveillance” programs that assess body weight in kids or by the well-meant education on “healthy activity and healthy eating” that may teach kids that obesity is simply a result of making poor choices and not moving enough (rather than a complex biopsychosocial chronic disease, that is highly resistant to lasting effects of time-limited interventions).

I would sincerely appeal to the researchers involved to amend their study protocol to include changes in weight bias, unhealthy weight obsessions, body image issues, and eating disorders both at the level of the kids and the community overall, to ensure that the well-meant interventions do not inadvertently replace one problem with another – as always, the Devil of public health interventions lies in the unintended consequences.

In fact, if I was on the ethics committee tasked with approving this study, I would insist that an in-depth assessment plan for the potential harm of this intervention be in place before commencement of any study related activities in the relevant communities.

If the overall goal of the WHO STOPS intervention is to have a healthier generation of kids, nothing is more important than fully understanding the potential impact of this intervention on mental health and social attitudes towards kids and adults living with obesity.

If you think the defining feature of obesity as a medical condition is the presence of a certain amount of body fat (e.g. greater than 20% in boys and greater than 30% in girls), then, as outlined in a systematic review and meta-analysis by Simmonds and colleagues, published in Obesity Reviews, BMI is a reasonably good measure (when compared to actual body composition as measured by densitometry (hydrostatic weighting or air displacement plethysmography), deuterium dilution, or DXA).

However, if you believe that the defining feature of obesity (in contrast to simple adiposity or fatness) should be a measure of whether or not excess or abnormal body fat actually impairs health in a given individual, then this analysis is not really helpful.

This distinction is important if we embrace the notion that obesity is a disease – a disease impairs health. A risk factor, on the other hand, is just that – a risk factor for a disease.

They are not the same.

Risk for diabetes is not diabetes.

Risk for heart disease is not heart disease.

Risk for cancer is not cancer.

Thus, the onus on anyone describing anyone as having the disease “obesity”, is to demonstrate that that person actually is “diseased” or in other words, is experiencing an impairment in health directly related to the presence of abnormal or excess body fat.

Thus, as this paper shows, BMI may well be a reasonable diagnostic measure of adiposity (more so in girls than in boys) – whether or not it helps diagnose obesity is another question entirely.

One of the papers presented at Obesity Week 2016 was work Paul von Hippel and Joseph Workman, published in Obesity, suggesting that virtually all of the weight gain in US kids from Kindergarten to Grade 2 happens during Summer vacations.

The researchers looked at data from the Early Childhood Longitudinal Study, Kindergarten Class of 2010–11, a nationally representative complex random sample of 18,170 U.S. children

All of the increase in the prevalence of obesity (which increased from 8.9% to 11.5% during the 2-year observation period), occurred during the two summer vacations.

Thus, the authors conclude that young kids are at greater risk of weight gain when they are out of school than in school.

As for the possible reasons, the researchers have this to offer,

“It is not clear whether children consume more food energy in the summer, but they do sleep less, and they watch more television. In addition, children in hot climates are less physically active during summer, although children in cool climates are more active.”

These findings may have important implications. Currently many health promotion programs focus on school interventions.

However, these data suggest that the time spent in school may not be the problem, which is in fact very much in line with the rather disappointing results from school intervention programs.

Rather, it appears that health behaviours at home may need to be the target of intervention, a much more daunting enterprise with no ready solutions.

Or, as the authors put it,

“Many school-based interventions have had little effect, and effective school-based interventions tend to be those that do not just alter the school environment but also involve parents and try to change out-of-school behaviors such as watching television. There may also be underexploited potential in out-of-school interventions such as summer camps, summer learning programs, parent nutrition education, reductions in screen time, and reductions in child-directed food marketing.”

Every two years the Canadian Obesity Network holds its National Obesity Summit – the only national obesity meeting in Canada covering all aspects of obesity – from basic and population science to prevention and health promotion to clinical management and health policy.

Anyone who has been to one of the past four Summits has experienced the cross-disciplinary networking and breaking down of silos (the Network takes networking very seriously).

Of all the scientific meetings I go to around the world, none has quite the informal and personal feel of the Canadian Obesity Summit – despite all differences in interests and backgrounds, everyone who attends is part of the same community – working on different pieces of the puzzle that only makes sense when it all fits together in the end.

The 5th Canadian Obesity Summit will be held at the Banff Springs Hotel in Banff National Park, a UNESCO World Heritage Site, located in the heart of the Canadian Rockies (which in itself should make it worth attending the summit), April 25-29, 2017.

Yesterday, the call went out for abstracts and workshops – the latter an opportunity for a wide range of special interest groups to meet and discuss their findings (the last Summit featured over 20 separate workshops – perhaps a tad too many, which is why the program committee will be far more selective this time around).

Childhood and adolescent obesity – research conducted with children and or adolescents and reports on the correlates, causes and consequences of pediatric obesity as well as interventions for treatment and prevention.

Obesity in adults and older adults – prevalence studies and interventions to address obesity in these populations

Clinical management – clinical management of overweight and obesity across the life span (infants through to older adults) including interventions for prevention and treatment of obesity and weight-related comorbidities

Rehabilitation – investigations that explore opportunities for engagement in meaningful and health-building occupations for people with obesity

Diversity – studies that are relevant to diverse or underrepresented populations

eHealth/mHealth – research that incorporates social media, internet and/or mobile devices in prevention and treatment

A few weeks ago, I was invited by the Editor of The Lancet Diabetes & Endocrinology to review Obesity in Canada, a collection of articles by Canadian and Australian authors, who identify themselves as “fat scholars” engaging in “critical fat studies”. (Edited by Jenny Ellison, Deborah McPhail, and Wendy Mitchinson).

Obviously, I have had multiple interactions with “fat scholars” over the years and have certainly always learnt a lot.

Indeed, I would be the first to admit that many of my own ideas about obesity, including the issue of whether or not obesity is a disease and, if so, how to define the clinical problem of obesity in a manner that does not automatically label a quarter of the population as “diseased”, has been shaped by this discourse.

Similarly, my own notions about obesity management, with a primary goal to improve health and well-being rather than simply moving numbers on the scale, are clearly influenced by ideas that first emerged from the “fat acceptance camp” (not exactly the same, but close enough).

Thus, there was certainly much in this compendium that I was already quite familiar with – which certainly made the reading of this 500 page volume most enjoyable.

Nevertheless, it is important to realise that “fat scholars” do not just see themselves as “scientists” – rather, they see the practice of “fat studies” as a political work, tightly (some might say dogmatically) bound to a frame of reference that is reminiscent of political “activism” rather than “science”.

Fat scholars (at least the ones represented in this volume) are not just critical of, but also appear most happy to discard the entire biomedical and population health discourse around obesity, as nothing more than (I paraphrase), “a thinly-veiled conspiracy by the biomedical establishment to create a moral panic that justifies the reassertion of normative identities pertaining to gender, race, class, and sexuality.”

Accordingly, some fat scholars appear to be of the rather strong opinion that there is in fact no “global obesity epidemic” and even if there are perhaps a few more fat people around today than ever before, the health consequences of obesity are vastly overblown, and any recommendations or attempts to lose weight are not only ineffective but actually harmful.

Now, before you simply roll your eyes and decide to file away the whole exercise in the drawer that you reserve for global-warming deniers and anti-vaxxers, let me assure you that there is indeed a lot to be learnt from the discourse (at least I did).

For one, there are absolutely fascinating chapters on the history of fat activism in Canada (which apparently dates back to the early 70s), enlightening perspectives on Indigenous People’s encounters with obesity, the issue of “mother blaming”, and even a chapter on fat authenticity and the pursuit of hetero-romantic love in Vancouver.

There are stories about how kids and families experience childhood obesity intervention programs and how primary school teachers themselves struggle with being thrust into a role of being role models while struggling with their own personal response to the pervasive obesity messages.

Obviously, there are some ideas that may be harder to swallow than others.

Take for e.g, the notion that the “root cause” of fat phobia (at least according to fat scholars who rely on postmodern feminism, psychoanalysis, and queer theories), is simply a reflection of the femininity ascribed to body fat: because women need fat to menstruate, body fat can be seen as female reproductive material that, in patriarchy, must be contained, restrained, and ultimately eliminated.

Personally, I can no doubt think of a wide range of other “root causes” that would result in “fat phobia” and “weight stigma” without having to quite delve into feminism or queer theories – but that’s another story.

Or the notion that there is in fact no link between body fat and diabetes – something that is easily refuted by a host of experimental animal studies and clinical observations (which, in the world of “fat scholars” do not appear to exist or are for some opaque reason deemed entirely irrelevant for the discourse).

Nevertheless, these “peculiarities” aside, I do admit that I found the book a very timely, relevant and enlightening read for anyone who is seriously interested in the issue of obesity and bold enough to step out beyond the typical biomedical discourse.

I would most certainly recommend this volume to people working in health policy and public health but also to clinicians, who seek to better understand some of the social aspects of the obesity discourse as it relates to their patients.

There is much in the volume that I perhaps disagree with or rather, see from a different perspective (I am after all a clinician) – however, openness to entertaining alternative views and ideas, and willingness to shift your own opinion and beliefs when new evidence emerges, is the defining characteristic of good scholarship – and I certainly remain a lifelong student.

@DrSharma
Edmonton, AB

Disclaimer: I was given a complimentary copy of Obesity in Canada to review by the Lancet Diabetes & Endocrinology